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Systems Plus College Foundation

Balibago, Angeles City

College Of Nursing

Nursing Care Plan

Student Nurse: Kimberly Trisha R. Concepcion

Yr/Level: 4th year Medical Diagnosis: DFS warning signs

Date: 09/19/13 Age: 16 Sex: F

Cues NursingDiagnosis

ScientificExplanation

Objectives NursingInterventions

Rationale Evaluation

S -

OMuscle grade

of 2/5With pallorPlatelet: 100 x

109 L

With V/S asfollows36.6 C89 bpm19 cpm150/70 mmHg

Risk forbleedingrelated toalteredclottingfactor

The circulatorysystem protectsitself fromexcessive bloodloss. Vascularinjury activatesplateletaggregation

which causesadherence ofcirculatingplatelets tocollagen fibersthat will activatethe adenosinediphosphatecauses plateletto breakdown

After 5 hours ofnursingintervention thepatient will beable to be freeof signs ofbleeding in GIaspirate or

stools, withstabilization ofHgb and Hct.

Note color andcharacteristics ofvomitus and stools.

The first step inmanaging bleeding isto determine itslocation. Bright redblood that does notclear signals recent oracute arterialbleeding, perhaps

caused by gastriculceration; dark redblood may be oldblood that has beenretained in intestine orvenous bleeding fromvarices. Coffee-ground appearance issuggestive of partiallydigested blood from

What is the color ofthe stool of thepatient?


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and sticktogether thatwill aggregatethe platelet toplug the wound.

Platelet areresponsible forclotting factor inour blood.(MedicalSurgicalNursing 2ndEdition, Udan2009)

Monitor vital signs;compare withclients normal andprevious readings.Take bloodpressure (BP) in

lying, sitting, andstanding positionswhen possible.

Note clientsindividualphysiologicalresponse tobleeding, such aschanges inmentation,weakness,

slowly oozing area.Undigested foodindicates obstructionor gastric tumor. In arapid upper GI bleed,

stool color may be redor maroon because ofrapid transit timethrough the GI tract.

Changes in BP andpulse may be used forrough estimate ofblood loss; BP lessthan 90 mm Hg andpulse greater than 110

suggest a 25%decrease in volume,or approximately1,000 mL. Posturalhypotension reflects adecrease in circulatingvolume. Note: Heartrate may not riseabove normal until upto 30% of total bloodvolume is lost.

Symptomatology isuseful in gaugingseverity and length ofbleeding episode.Worsening ofsymptoms may reflectcontinued bleeding,inadequate fluid

What are the vitalsigns of thepatient?

Did the patientmanifest anychange in mentalstatus?


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restlessness,anxiety, pallor,diaphoresis,tachypnea, andtemperature

elevation.

Monitor intake andoutput (I&O) andcorrelate withweight changes.Measure bloodand fluid losses viaemesis and stools.

Keep accurate

record of subtotalsof solutions andblood productsduringreplacementtherapy.

Maintain bedrest;prevent vomitingand straining atstool. Schedule

activities to provideundisturbed restperiods. Eliminatenoxious stimuli.

Note signs ofrenewed bleedingafter cessation ofinitial bleed.

replacement, andshock.

Provides guidelinesfor fluid replacement.

Potential exists for

overtransfusion offluids, especially whenvolume expanders aregiven before bloodtransfusions.

Activity and vomitingincreases intra-abdominal pressureand can predispose to

further bleeding.

Increased abdominalfullness anddistention, nausea orrenewed vomiting, and

What is the I & O ofthe patient? Did thepatient experiencefluid loss?

Did the patient

need a bloodtransfusion?

Did the patientunderstands theinstructions given?

Did the patientexperience arenewed bleeding?


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Observe for

secondarybleeding from noseor gums, oozingfrom puncturesites, orappearance ofecchymotic areasfollowing minimaltrauma.

Provide clear orbland fluids whenintake is resumed.Instruct to. Avoidcaffeinated andcarbonatedbeverages.

Instruct to avoiddark colored foods.

Instruct to avoidAspirin intake.

bloody diarrhea mayindicate return ofbleeding.

Loss of or inadequate

replacement of clottingfactors may precipitatedevelopment ofDisseminatedIntravascularCoagulation.

More easily digestedand reduce risk ofadded irritation toinflamed tissues.Caffeine andcarbonated beveragesstimulate hydrochloricacid (HCl) production,possibly potentiatingbleeding.

Dark colored foodsthat will darken thestool. That you mayconfuse it withbleeding.

Aspirin is an anti-platelet medicationthat prevents forming

Did the patient

experiencesecondarybleeding?

Did the patientunderstand theinstructions given?

Did the patientcomply with theinstructions given?

Did the patientcomply with theinstructions given?


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Monitor laboratorystudies: Hgb, Hct,RBC count, and

BUN/creatininelevels.

Administermedications, asindicated:Protonpump inhibitors(PPIs), such asomeprazole.

clot

Aids in establishingblood replacementneeds and monitoring

effectiveness oftherapy; for example,1 unit of whole bloodshould raise Hct twoto three points. Levelsmay initially remainstable because of lossof both plasma andRBCs. Note: Levelsmay not accuratelyreflect early or sudden

blood loss, and lowbaseline levels mayindicate preexistinganemia. BUN greaterthan 40 with normalcreatinine levelindicates majorbleeding. BUN shouldreturn to clientsnormal levelapproximately 12

hours after bleedinghas ceased.

Proton pump inhibitorshave been shown instudies to be mosteffective after GI bleedto reduce recurrenceof bleeding.

What are thelaboratory results ofthe patient?

Did the patientmanifest anyrecurrence ofbleeding aftertaking themedication?


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Cues NursingDiagnosis

ScientificExplanation

Objectives NursingInterventions

Rationale Evaluation

SNaiinip naako dito

O

Muscle gradeof 2/5

LethargicMoves from

side to side

RestlessnessLack of

interest ineating

With V/S as

follows36.6 C89 bpm19 cpm

150/70 mmHg

Deficientdiversional

activity relatedto

environmentallack of

diversionalactivity as

evidenced byrestlessness

The nervoussystemprofoundlyaffects both

psychologicaland physiologicfunctions. Itreceives stimulifrom the internaland externalenvironmen5through a variedafferent orsensorypathways that

willcommunicatesinformationbetween thedistant parts ofthe body toCNS that willalso transmitsinformationrapidly overvaried efferent

or motorpathways toeffector organsfor body actioncontrol ormodifications.(MedicalSurgicalNursing 2

nd

Edition, Udan

After 4 hours ofnursing

intervention, thepatient will be

able to engagein satisfying

activities withinpersonal

limitations.

Assess/reviewclients physical,cognitive,emotional, and

environmentalstatus.

Determineavocation andhobbies clientpreviously pursued.

Incorporateactivities, ifappropriate, intopresent program.

Introduce activitiesat clients currentlevel of functioning,progressing to morecomplex activities,as tolerated.

Establishtherapeuticrelationship,acknowledgingreality of situationand clientsfeelings.

Validates reality ofdiversional deprivationwhen it exists, oridentifies the potential

for loss of desireddiversional activity, inorder to plan forprevention or earlyintervention wherepossible.

Encouragesinvolvement and helpsto stimulate clientmentally and physically

to improve overallcondition and sense ofwell-being.

Provides opportunityfor client to experiencesuccesses, reaffirmingcapabilities andenhancing self-esteem.

May be feeling senseof loss when unable toparticipate in usualactivities or to interactsocially as desired.

What is thepatients physical,cognitive, emotionaland environmental

status?

What are thepatients hobbiesbeforehospitalization?

Did the patientcomply with theactivity?

Determine what thepatient feels abouther situation?


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2009) Participate indecisions abouttiming and spacingof visitors, leisureand care activities

Encourageparticipation in mixof activities andstimuli, such asmusic, newsprogram,educationalpresentations,crafts, and social

interactions, asappropriate.

Provide change ofscenery whenpossible, alterpersonalenvironment.

To promoterelaxation/reducesense of boredom aswell as preventoverstimulation and

exhaustion.

Offering differentactivities helps client totry out new ideas anddevelop new interests.

Activities need to bepersonally meaningfulfor the client to derivethe most enjoymentfrom them such as

talking or Braille booksfor the blind andclosed-caption TVbroadcasts for the deafor hearing impaired.

Stimulates energy andprovides new outlook

for client.

Did the patient feelcomfortable?

Did the patientparticipate in thegiven activity?

Did the patient feelcomfortable?


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Systems Plus College Foundation

Balibago, Angeles City

College Of Nursing

Drug Study

Student Nurse: Concepcion, Kimberly Trisha R.

Yr/Level: 4th

year Medical Diagnosis: DFS warning signs

Date: Sept 14, 2013 Age: 16 Sex: F

Name Of The

Drug

Date Ordered

Date Started

Date Changed

Date

Discontinued

Route Of

Administration

Dosage And

Frequency Of

Administration

General

Action

Specific Action Indication Clients

Response With

Actual Adverse

Reactions

GENERIC

NAME:

Omeprazole

BRAND

NAME:

Prilosec

DO: Sept 12,

2013

DS: Sept.12,

2013

Oral 20 mg/cap BID

Given @ 8am

Proton Pump

Inhibitor,

Antisecretorydrug

Gastric acid-pumpinhibitor: Suppresses

gastricacid secretion by specificinhibition of thehydrogen-potassium

ATPase enzyme systemat the secretory surface ofthe gastric parietalcells; blocks the final step

of acid production.

Reduction of riskof upper GI bleeding

in critically illpatients;includes sodium

bicarbonate

The patient did

not manifest any

upper GIbleeding.


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Contraindication:

Contraindicated with hypersensitivity to omeprazole or its components.

Use cautiously because of possible increarisk of Clostridium difficile infection.

Adverse effects CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongueatrophy Respiratory: URI symptoms, cough, epistaxis Other: Cancer in preclinical studies, back pain, fever, decreased bone density, bone fractures

Nursing Responsibilities:

Assessment

History: Hypersensitivity to omeprazole or any of its components, pregnancy, lactation Physical: Skin lesions; T; reflexes, affect; urinary output, abdominal examination; respiratory auscultation

Administer before meals. Caution patient to swallow capsules wholenot to open, chew, or crush them.Administer antacids with, if needed as per doctors order. If patient cannot swallow Prilosec capsules, contents of capsule may be added to or sprinkled on 1 tablespoon applesauce. Mix capsulecontents into applesauce and have patient swallow immediately without chewing pellets. Follow with a glass of water.

Teaching points Instruct the patient to take the drug before meals. Swallow the capsules whole; do not chew, open, or crush them.If using the oral suspension, empty packet into a small cup containing 2 tablespoons of water.Stir and drink immediately; fill cup with water anddrink the water. Do not use any other liquid or food to dissolve the packet. This drug will need to be taken for up to 8 weeks (short-term therapy) orfor a prolonged period (more than 5 years in some cases). If you take Prilosec capsules and cannot swallow them whole, capsule contents may be added to or sprinkled on 1 tablespoon of applesauce.Mix with applesauce, swallow immediately without chewing pellets, and follow with a glass of water. Have regular medical follow-up visits. You may experience these side effects: Dizziness (avoid driving or performing hazardous tasks); headache (request medications); nausea,vomiting, diarrhea (maintain proper nutrition); symptoms of URI, cough (do not self-medicate; consult your health care provider if uncomfortable). Report severe headache, worsening of symptoms, fever, chills, severe diarrhea.


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Diagnosis: DFS warning signs

Name Of The

Drug

Date Ordered

Date Started

Date Changed

Date

Discontinued

Route Of

Administration

Dosage And

Frequency Of

Administration

General Action Specific Action Indication Clients

Response WithActual Adverse

Reactions

GENERIC

NAME:

Immunosin

BRAND

NAME:

Inosiplex

DO: Sept 12,

2013

DS: Sept.12,

2013

Oral 500 mg/tab

6o

Given @ 8am

Immunostimulant It stimulates the immune

system by inducing

activation or increasing

activity of any of itscomponents. One notable

example is the

granulocyte macrophage

colony-stimulating factor.

To shorten the

course of illness

and to boost the

immune system.

The patient did

not experience

any adverse

effects. Thepatients white

blood cells is

within the

normal range.

Contraindication:Patients with

Gout Renal disorders Sever gastric ulcers Pregnancy and lactation

Adverse effects:

Elevation of serum and urine uric acid values which will return to normal of the cessation of drug administration.


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Nursing Responsibilities:

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